Nature intended that women would give birth vaginally. It also designed that babies would turn to the head down position ready for labour. The uterus is strong muscle. It draws the cervix up to shorten and open it. This allows the baby’s head through. Then when the mother starts pushing in time with those strong contractions, the baby moves down the birth canal as is born. For the majority of pregnancies, a vaginal birth is the safest for both mother and baby. But it is true that for some women or their babies, a spontaneous vaginal birth isn’t safe. They may need an assisted vaginal delivery or even a caesarean section.
What is Normal Vaginal Delivery?
Normal vaginal delivery refers to a woman going into natural labour after 37 weeks of pregnancy and the delivery of the baby with the support of her birthing team. Without intervention. Around the world the majority of babies are born this way.
In modern obstetrics and neonatal care, a number of risks have been identified which can lead to a poor outcome for the mother and/or the baby. This is why pregnancy is so closely monitored throughout. This means that interventions such as induction of labour may be necessary if there are complications. For example, a baby that isn’t growing well, diabetes in pregnancy, blood pressure problems or a pregnancy that has gone beyond 40 weeks. For a small number of these women the induction process won’t get her into labour. Or the baby may not tolerate the stress of labour and a caesarean section may be necessary.
The pain of labour doesn’t seem to serve a clinically useful purpose. For this reason, many women opt for an epidural to reduce or remove the pain of contractions. The benefit of an epidural is that it reduces the woman’s stress hormones and can make the birth experience much better. The disadvantage of an epidural is that the numbness may make it difficult for the woman to push effectively. This increases the chance of needing an assisted vaginal delivery. Such as a vacuum or forceps delivery if the birth is progressing too slowly or the baby is becoming distressed. Around 30 to 50% of women having an epidural have an assisted vaginal delivery. Having an epidural does not increase the risk of an emergency caesarean.
Planned Caesarean Section
For some women and babies a planned caesarean section is the safest choice. This might be because the mother is seriously unwell, the baby may to too small to tolerate the stress of labour, the placenta is lying over the cervical opening or the baby hasn’t turned to be head down. There are other reasons why a planned caesarean may be best. It’s not clear what percentage of planned caesarean section is acceptable and safe for the population. But it’s probably around 10 to 15% with a further 15 to 20% of women needing an emergency caesarean.
This has led to the misconception that caesarean section is safer than a vaginal delivery in all cases. There are pros and cons to both vaginal delivery and caesarean section. The most important thing is a careful risk assessment and balanced discussion with your obstetrician about your individual circumstances. Any surgical procedure carries risks. There is evidence that having caesarean sections limits family size.
There is an increase in the risk of low-lying placenta (placenta praevia) after any caesarean. The risk increases with the number of caesareans. Placenta praevia is a significant risk as it makes subsequent caesarean more complex. It increases the risk of a blood transfusion and increases the risk of an emergency hysterectomy at the time of delivery. Bearing in mind this uncommon but serious risk, obstetricians only recommend caesarean section if it is really the safest thing for the current pregnancy. They are considering the future risks as well. For this reason, caesarean section for maternal request alone needs a detailed discussion with your obstetrician. This simple table gives you some idea of the things to consider.
Delivery Choices After Previous Caesarean Section
If a woman has had one previous caesarean section it may be safe for her to have a vaginal delivery in a later pregnancy. There is a consensus between the Royal College in the UK and the American College of Obstetrics and Gynaecology that vaginal birth after caesarean section (VBAC) is safe for the majority of women.
Around 72 to 75% of women attempting VBAC have a successful vaginal delivery. This rises to 85 to 90% if the woman has also had a vaginal delivery in the past. There are a small number of conditions which would mean that repeat caesarean would be safer. For example, if the woman has had more than one caesarean in the past or if the placenta is lying over the cervix. Your obstetrician will give you advice about the safety, chance of success and advisability of attempting VBAC based on your individual circumstances.
There are both pros and cons to VBAC and to repeat caesarean section. Your obstetrician can explain this to you but this simple table gives you some idea of the things to consider.
If the pregnancy is uncomplicated for both mother and baby the best time to have a repeat caesarean section is after 39 weeks. This is because babies born by caesarean section, without going into labour, before 39 weeks have an increased chance of breathing difficulties. They often need to go to the neonatal intensive care for oxygen treatment or help with breathing. If your obstetrician is concerned about you or your baby and wants to deliver you by caesarean section before 39 weeks, they may recommend steroid injections. This is to help mature your baby’s lungs and reduce the risk of breathing problems.
In conclusion it is important to remember that childbirth by whichever method is safe. Especially in a setting like the Cayman Islands. The risks for any mode of delivery are very small. The best person to discuss the pros and cons with you is your obstetrician. They will be familiar with your past obstetric history, your medical history and how your current pregnancy is progressing. They will be able to give you advice specific to your circumstances.